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FIRST - Firefighters

Stress and Violence in fire-based EMS Responders (SAVER)

While much of the work by the Center for Firefighter Injury Research and Safety Trends (FIRST) has focused on the injury and safety outcomes of firefighters, our research focus has grown to be inclusive of fire-based Emergency Medical Services (EMS). In the United States, EMS is responsible for as much as 70 to 90 percent of the work done by fire departments. With calls increasing approximately 20% each year (NEMSIS, 2016), EMS responders are increasingly expected to do more with less. Increased call volume and exposure to patients increases the risk for injury and illness for EMS responders. Read more about how increased call volume and other industry strains affect EMS responders in A Strained 9-1-1 System and Threats to Public Health.

Despite working in a profession characterized by helping people, an estimated 2,100 EMS workers visited U.S. hospital emergency departments in 2011 to treat an injury resulting from patient violence (CDC, NIOSH Workplace Safety, 2013). Previous research by the FIRST Center confirmed the issue of patient violence by using data from the National Fire Fighter Near-Miss Reporting System (NFFNMRS), a secure and non-punitive reporting system created by the International Association of Fire Chiefs. We reviewed emergency medical call reports and analyzed their narrative text fields. Of 185 reports, violence (n=48) was the most commonly identified mechanism of near-miss or injury. We found that emergency medical responders were threatened or assaulted by patients, as well as family members and bystanders. Common underlying factors included: violent patients, patients with mental health issues, and patients with particular health conditions (e.g. seizure, hypoglycemia). Read more about injuries EMS responders experience in Injury Risks of EMS Responders: Evidence from the National Fire Fighter Near-Miss Reporting System.

From a local perspective, this problem of violence affects the Philadelphia Fire Department (PFD)--an urban, inner city department serving 1.5 million people. Data from the Firefighter Injury Research and Safety Trends (FIRST) project served as a catalyst to investigate this particular issue more deeply. We gathered injury data from the Philadelphia Fire Department Safety Office for the period 2005-2011 and analyzed it by cause of injury stratified by males and females. Most causes of injury were of equivalent proportion between males and females. However, the “struck by” category showed a disproportionate percentage of females (22%) who reported this cause of injury compared to their male counterparts (9%). To investigate the “struck by” injuries more deeply, the narratives from the first reports of injury were reviewed. These narratives often referred to violence by a patient as the injury cause. However, most females in the PFD are paramedics, so we stratified by occupation and the gender difference disappeared. But paramedics (compared to firefighters) were 14 times more likely to experience a struck by injuries from a patient. Read more about violence against EMS responders in Expecting the Unexpected: A Mixed-Methods Study of Violence to EMS Responders in an Urban Fire Department.

To view the media's perspective on patient-initiated violence to paramedics and EMTs, read "Banged Up and Burned Out: Assaults by Patients Against Paramedics & EMTs".

In September 2017, the FIRST Center was awarded a $1.5 million dollar grant by FEMA for the project, “Stress and Violence in fire-based EMS Responders (SAVER),” which responds to seven of FEMA’s national prevention priorities on firefighter safety projects “designed to measurably change firefighter behavior and decision-making”. SAVER is the first FEMA R&D grant to address the EMS side of fire. 

SAVER is investigating the organizational, mental health, and injury burden that fire-based EMS responders carry as they respond to an increasing community demand for services. 

SAVER Systems Checklist 


Using findings from a USFA/IAFF-funded systematic review of academic and industrial literature conducted by FIRST, we developed a systems-level checklist for violence against fire-based EMS responders that speaks to each phase of emergency response, including two new phases that emerged as a result of our analysis of the literature. Read USFA Mitigation of Occupational Violence to Firefighters and EMS Responders for insight into this analysis.


The SAVER Systems-level Checklist is an innovative application of traditional checklists, designed to shift the onus of safety and health from that of the individual first responder to the organization by focusing on actions that the leadership team (departments and union) can institute through training, policy, and environmental modifications. In July 2018, the FIRST Center convened 41 diverse subject matter experts representing 27 different fire service and EMS organizations, government, academia, unions, and fire departments for the two-day “Systems Checklist Consensus Conference (SC3)” to facilitate consensus-building, collaboration, and evaluation of the checklist. During the two-day meeting, national stakeholders came to consensus on the efficacy, utility, and usability of the systems-level checklist.  



Check out "Drexel conference focuses on how to keep EMTs safe from violence" for a media perspective on this issue.


The systems checklist is being implemented with our partnering fire departments in Dallas, Philadelphia, and San Diego. Evaluation of the checklist’s effectiveness uses a mixed methods approach: interviews and focus groups combined with a quasi-experimental repeated-measures design using validated psychological scales for organizational outcomes (burnout, engagement, job satisfaction, etc.), mental health outcomes (depression, PTSD, etc.), and injuries pre- and post- intervention.


Learn More on how to implement the SAVER Systems Checklist in your department



EMERG Violent Reporting System


There is no uniform system that captures verbal and physical violent exposures to fire-based EMS responders. SAVER modified an existing violent-event reporting system provided by the Center for Leadership, Innovation, and Research in EMS (CLIR) to increase reporting of verbal and physical violence.  When possible, reports are cross-referenced with workers’ compensation claims for violence-related physical injuries to evaluate under-reporting. Additionally, all EMS calls to the participating fire departments will be analyzed by linking dispatch data to patient care reports to better understand community need and clusters of high utilization. A detailed analysis on all calls that result in verbal or physical injury to firefighters will also be conducted.


Learn More About the Confidentiality Protections of the EMERG Violent Event Reporting System


Ultimately, the funding provided by FEMA allows the FIRST Center to study the complexities of violence against EMS responders by obtaining baseline frequency and variability of assault, along with other contributing circumstances to these events (e.g. legal system, community expectations, work environment, etc), and increasing violence reporting mechanisms. Once this baseline is firmly established, the path will be laid for the development of targeted interventions to reduce violence to EMS workers.


If you would like more information about our EMS portfolio or interested in telling us more about your experience, please e-mail FIRST Senior Project Manager, Andrea Davis, 


Find out more on our work addressing violence against EMS Responders:

A Systematic Review of Workplace Violence Against Emergency Medical Services Responders

Creation of a Systems-Level Checklist to Address Stress and Violence in Fire-Based Emergency Medical Services Responders

OSHA Executive Summary: Violence Against Emergency Medical Services (EMS) Responders

Mitigating Violence Against First Responder Teams: Results and Ideas From the Hackmanathon